Permit Community Development
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.dgard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR T ITEM(S) CHECKED ( ✓): V 0 1
CANCEL PERMIT APPLICATION.
n REFUND PERMIT FEES (attach receipt, if available). � /2.1 //i
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). 47 4 9 1-- .
Permit #: QtnP6— (poxi -(
Site Address or Parcel #: 9 ((J9 ,s(A). 3(_,, r n/ &iin
Project Name: f t ; ,A
Subdivision Name: —� Lot #:
EXPLANATION: i 1 l rl • I . 10 A i. . I A °)'v/ a
Signature: �` _ . Date: 4 7 i /5 — /j
MN"
Print Name: 8 I a Ki--
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date L Mr= B ?p Rte to Bld: Admin: Date An= B
Refund Processed: Date il/ /,/ By ,7,1 Invoice Processed: Date By
Permit Canceled: Date oa/ <f B :: -arcel Tat Added: Date B
Receipt # Date Method Amount $
I: \Building \Forms \ReqPermitAction.doc Rev 07/26/07
Building Permit Application 0 1 D �'/''
€oinier ° q ° ‘ fb FOR OFFICE USE ONLY
l ---
City of Tigard , \. ^ i A s, ti DateB : .1/ Permit No: / •' I l ..r
IPP
° 13125 SW Hall Blvd., Tigard, OR 97223 <� Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 F \-- Received
s� ; V a Date/B : Other Permit:
T IGARD Inspection Line: 503.639.4175 .{�; �� ,` \ . e Date Ready /By: luris: ® See Page 2 for
El
Internet: www.tigard- or.gov 1( \1 ' i n �� : Notified/Method: 6 , Supplemental Information
r'.i a OV �o
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3,
i „t,,,, 3 ..H =., . r ", > ' f : ' •TYPEi F .W It : , :q , ; ; RE UIRED=DA »T 7, 4. 2'EA141I Y DW'EL IN
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❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
❑ Addition/alteration/replacement her: 6 I 6 equipment, materials, labor, overhead, and the profit for the
,,;. -;' £s,.. ya.:c -a;;£ ,,,;,: r a ", '- work indicated on this application.
�s ,. � >. '.�_. �;�..',C TE�,t�Ith O,F,: GOIVS'I'ItUCTIt}1V,� „'•,:.�„'� ~'f;, , r�,� .
�'�'?` "�;t:�;:, x °ff9��3,x .,,��'rat`a.. r,;,8���'m. ter _ :. sib .'i.PSa,iE;;•;>:'E: =at<4; , ,,. ��''�� 3: �:, "•''',: ; t...r
❑ ` 1- and 2- family dwelling 02ommercial /industrial Valuation: $
1=1 Accessory building ❑ Multi- family Number of bedrooms:
El Master builder El Other:
Number of bathrooms:
3 x'''r , ""'"'''r!''''' [P1F = R -A ':; '--' ' `;,>. F S_ Total number of floors:
pr•:�v_: <-�� =.., .,. ..., A; 0, hTti ���Q � .�_.� �>a�3:`y�:::e� .!, t,> .„
l
Job site address: 9 I 6 9 ,c i A 1
ti _ 0. . `Kd New dwelling area: square feet
City/State/ZIP-1' ( ) 0p 9 Z2 LI Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: '756,(4 V I%1Q'h CvevacLA-, Covered porch area: square feet
Cross street/directions to job site: _ .. . a. ` 2 j.. Q.. Deck area: square feet
Other structure area: square feet
? `IiEQLiiii 1 DATA -0014IlYIETiCth iISE CFIECKL1STa
Subdivision: Lot no.: Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
Tax mno.:
Tax " "- map/parcel a , c :, : l n £< -, � ; , , ,. =.`t:,t:•,. ..,, and the profit for the
equipment, materials, labor, overhead, a e r
°, . :,:< N »a> : : %` 3>r %' r:: �.,m work indicated on this a lication.
1 ' b .,..,,* ':` F 'i I),E bN OF sWC1RK„ , „ ,n�,,,h PP
• � °',;�` %, ,,:r'��s + , �;< , »�'�:n.. t E,. .. ' , :. �F „y,;x. F:,, :., >, ,.. ��rs "; `_.. >...,,...�t:� , _ -, H _
Y1OAA. ) YL SMA 1 1 m vv ' S 1 �1 ►� Valuation: $ 1 aQ
J Existing building area: square feet
New building area: square feet
r', 3,y ° TENANE ' Number of stories:
�i , .., � ��. a�.�� ':�.., ..
' ❑>.� �';_'., ,�
e�,s. ...., �� €ns, ^, a?.�..x....,- n�..:'::,e�a��';., at' +'e.�. . ,..a .....::\ \rn,.:� ��'za \ca.. >= ,.L��,.�a'�i.i e, .,.`, ' i:• , x. "d,3,':ta x'
Name: f ,f ,... S r), ..: -- 449_.... „ " \ Type of construction:
.!9 +J.+tL�
Address: Occupancy groups:
City /State /ZIP: Existing:
Phone: ( gcy _ I 7 i (9 Fax: ( ) New:
,.�.. �.AT'ELTCAN "I' _,..,, ..,.. :- .CONTAG�T, =;:PERSON.'
pp N r C'E °';'_
r ,Nw tl3Ei ;;,�?�'e '`�`� < ^.�a�itiRa�Z =e <.s ,..,,. 1! : <,�: "3 -g.... .a�",. .,
Business name: 'P r t C N All contractors and subcontractors are required to be
licensed with the Oregon Construction Contractors Board
Contact name: J
J(1. 0 Imo_ under ORS 701 and may be required to be licensed in the
Address: 1- a QS (..)...) '14+ _ jurisdiction in which work is being performed. If the
City /State /ZIP: - 1 b� Ci 1 aQ 4
applicant is exempt from licensing, the following reasons
�, apply:
Phone: (Jw l � '3 ( t ! _ 2 _ 2 _ , F a x : : ( c 1 3 ) -,(0L/ _ <4 3 is-- E -mail: �
ti -:. z := , yr. `' _ .
= '?::;; , , . >a ., ;C -,:,: , "-u.,., r%r net.itt
,
,�
Business name: ,, Etf S t CO ,s` , _ , 'N ; $1JILDINGsP-El 1 , FI ES- . l' �x< t� »;:
Address: I C M< -' o_f '`: r Olease-.°r<"efe'r toJ`ee.sekedid w c
! S oZ 0-:-.-- Sly T— Structural plan review fee (or deposit):
City /State /ZIP: --(�' , q
' 'S°��` ► �� ! 2.2 FLS plan review fee (if applicable):
Phone: ( S?) .�(o ` 2 Z /I Fax: ( 3) 3 b`l ` .y3lf
I Total fees due upon application:
CCB lic.: 1p Li Q 1 ✓ r�'�
Amount received: 0.7, cif-) --
Authorized signature: / 0 This p ermit a ex if a p er it is not obtained
4 within 180 days after it has been accepted as complete.
v
Print name: ( ��, 4 ...L5 - e , Q ��- Date: 2 /2/ / 7/ * Fee methodology set by Tri- County Building Industry
l ! Service Board.
1: \Building \Permits \BUP -COM PermitApp.doc 10/01/09 440-4613T( I I /02/COM/WEB)